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ADVANCING
YOUR PRACTICE
Get a real-world
education through simulation
By Charles W. Fort, MSN, RN
Your patient, James, just coded again.
You begin CPR while you wait for the code team to arrive. When
help arrives, he's promptly and appropriately managed according
to advanced cardiac life support (ACLS) guidelines and he's successfully
resuscitated.
This is the eighteenth time James
has coded today. That's because he's a human patient simulator
used to teach healthcare professionals how to recognize and respond
to medical emergencies.
Human patient simulators are anatomically
accurate manikins that are computer-controlled to provide a realistic,
real-time simulation of patient conditions. You'll assess and
treat these lifelike simulators using real procedures and equipment,
and they respond to treatment the way a real patient might. In
this article, I'll review the different types of simulators available
and how they can help you improve your nursing practice.
What's simulation?
You had a lot of experience with one type of simulation in nursing
school when you discussed case studies and engaged in role playing,
using fictional examples based on real patient scenarios to reinforce
learning. But case studies and role playing offer few opportunities
for hands-on experience.
Basic simulators, also known as partial
task trainers, include intubation heads, I.V. insertion arms,
and central venous access torsos. You may have used them in school
or in ACLS courses to get hands-on experience by practicing a
particular skill. But partial task trainers aren't designed to
teach complex tasks that incorporate the whole patient with associated
environmental factors. That's where human patient simulators come
in.
Learning by doing
Human patient simulators help you learn by doing. Confucius said,
"I hear and I forget. I see and I remember. I do and I understand."
Research has shown that nursing students retain knowledge learned
during a simulation longer than when the same skill is taught
in a traditional way.1
Patient simulators are often used
during orientation to objectively measure competency in certain
technical skills.2 A demonstration of a cardiopulmonary
arrest scenario can orient new nurses to how codes are run according
to facility policy. If a new nurse (or one transferring to a different
area of a facility) has trouble adapting to a new department,
simulation can help improve critical thinking skills, nursing
competencies, and confidence.
Simulation allows clinicians to break
down complex tasks into smaller components so they can learn at
their own rate. Important skills such as hand hygiene, documentation,
and communication can be incorporated into every simulation.
Meet some simulator types
The various types of human patient simulators available are categorized
by their capabilities and how they're controlled. Basic models
are full- or nearly full-bodied static manikins that have features
such as oral and nasal airways that accept intubation, and can
generate cardiac dysrhythmias, including ventricular fibrillation
that responds to defibrillation. They have no electronic feedback
capability.
Intermediate models have some feedback
capability and can be programmed via computer to provide specific
clinical indicators, such as heart rate, BP, oxygen saturation,
and respiratory rate. These can be assessed directly from the
manikin or through a patient monitor.
Advanced models react to treatments
and interventions such as oxygen administration, medication administration,
and needle chest decompression. Scripted computerized scenarios
change and adapt according to the clinician's interventions Advanced
simulators provide the most clinical feedback because of features
like these:
- carbon dioxide exhalation to
assess quantitative end-tidal carbon dioxide
- air return with needle chest
decompression
- bloody fluid drainage with chest
tube insertion
- urine output with urinary catheter
insertion
- peripheral pulse palpation; pulse
intensity varies with BP.
Simulation sites: Setting
the stage
Simulation can be performed in the unit or a simulation lab. Both
options have pros and cons. In a simulation lab, the human patient
simulator and the whole clinical "stage" can remain
set up and ready for use, and nurses can work with fewer distractions.
On the other hand, if the simulator is brought to the unit, nurses
can perform their normal roles where they're most comfortable
and use real patient-care equipment. Working in the unit may reveal
issues that might not have come to light in the simulation lab.
See Simulator shortcomings for a discussion
of potential drawbacks to each training option.
A simulation is run by a simulator
facilitator or instructor who has the clinical knowledge to guide
the simulator through a realistic scenario. Following a simulation,
you receive immediate feedback during a debriefing, which may
be the single most valuable aspect of simulation learning. At
the debriefing, you and the simulator facilitator or instructor
can discuss what went well and not so well. The opportunity to
detect and correct errors in performance helps you sharpen your
clinical skills without patient risk. After the debriefing, you
may go through the scenario again to practice the "correct"
way.
Pros and cons
Simulation has several advantages over traditional teaching methods,
such as lecture:
- Simulation lets the nurse make
mistakes, follow the mistakes to their conclusion, and learn
from the consequences without harming the patient.3
- Simulation can decrease feelings
of anxiety and failure that some nurses experience if they haven't
yet mastered a skill.4
- Simulation lets the new nurse
develop a process of critical decision making and improve self-confidence
in a safe and controlled environment.
- Simulation lets the nurse practice
clinical skills that are high risk but are used infrequently.2
Simulation scenarios with critical
situations can help desensitize you to emergencies and keep you
from letting your anxiety get the better of you. Even experienced
nurses can benefit from practicing how to intervene in rare but
potentially lethal complications, such as massive hemorrhage or
shoulder dystocia.5
Future simulators
Soon, human patient simulators like James will have new colleagues.
Completely wireless models are now available, so you can use them
in any setting. For example, you could stage an ED scenario by
starting the simulator, throwing it over your shoulder, and carrying
it into the ED, saying, "My buddy just got shot."
As computer technology improves,
so will the capacity of human patient simulators to act and react
more like real human beings—who knows, one day you might
find it hard to tell the difference!
Simulator
shortcomings
Even though human patient simulators provide opportunities
for hands-on learning, they can't replace the experience
you get by working with real patients and interacting with
colleagues.1 Human patient simulators are expensive,
costing from $40,000 to $250,000 each, and they require
someone to operate them who has enough knowledge to ensure
that the simulated scenario is clinically accurate and meets
learning objectives. The simulator facilitator or instructor
has to be able to program and control the human patient
simulator, which requires training and experience. Simulation
can be labor intensive and time consuming. Faculty need
to be trained in how to use the simulator, how to let the
participant make mistakes, and how to debrief properly,
or the educational session isn't as beneficial.
If the simulator is used in
a remote lab, it needs to duplicate the clinical environment
it represents. A simulation lab requires dedicated facility
space, which is often a precious commodity in the hospital.
Sometimes the realism of the simulation isn't real enough,
and some nurses can't suspend their disbelief enough to
take the simulation seriously.
If the human patient simulator
is used in an actual clinical space, the simulation has
to be scheduled so it doesn't interfere with actual patient
care. With no simulation lab, secure storage must be found
for the simulator and its related equipment.
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References
1. Childs JC, Sepples S. Clinical teaching by simulation: lessons
learned from a complex patient care scenario. Nurs Educ Perspect.
2006; 27(3):154-158.
2. Ackerman AD, Kenny G, Walker C. Simulator programs for new
nurses orientation. J Nurses Staff Dev. 2007;23(3):136-139.
3. Hravnak M, Tuite P. Expanding acute care nurse practitioner
and clinical nurse education: invasive procedure training and
human simulation in critical care. AACN Clin Issues.
2005;16:89-104.
4. Winslow S, Dunn P, Rowlands A. Establishment of a hospital-based
simulation skills laboratory. J Nurses Staff Dev. 2005;21(2):
62-65.
5. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories
for training in obstetrics and gynecology. Obstet Gynecol.
2003;102(2):388-392.
Source: Nursing2009.
November 2009.
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